Español (Spanish) - ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística llame al (Language Line Number).

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2 The Fulton County Ryan White Part A Program and subrecipients comply with federal, state, and local prohibitions against discrimination on the basis of race, color, national origin, disability, age, sexual or gender identity, genetic information, and religion. Fulton County is an equal opportunity employer encouraging diversity. If you need reasonable modifications due to a disability, including communications in an alternate format, please contact (404) For TDD/TYY or Georgia Relay Service Access, dial 711. Fulton County Government hereby gives public notice that it is the policy of the County to assure full compliance with Title VI of the Civil Rights Act of 1964, the Civil Rights Restoration Act of 1987, and related statues and regulations in all programs and activities. It is our policy that no person in the United States of America shall, on the grounds of race, color, national origin, sex, age, or disability be excluded from the participation in, be denied the benefits of or be otherwise subjected to discrimination under any of our programs or activities. Any person who believes they have been subjected to unlawful discriminatory practice under Title VI has a right to file a formal complaint. Any such complaint must be filed in writing or in person with Fulton County Government, Title VI Coordinator, within one hundred-eighty (180) days following the date of the alleged discriminatory action. Title VI Discrimination Complaint Forms may be obtained from the Equal Opportunity Division by calling (404) Español (Spanish) - ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística llame al (Language Line Number). 繁體中文 (Chinese) - 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (Language Line Number). Tiếng Việt (Vietnamese) - CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (Language Line Number). 한국어 (Korean) - 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. (Language Line Number) 번으로전화해주십시오. 1 Fulton County Part A Program Manual June 2016

3 Русский (Russian) - ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (Language Line Number). ت تواف ر ال ل غوي ة ال م ساعدة خدمات ف إن ال ل غة اذك ر ت تحدث ك نت إذا :م لحوظة - (Arabic) ال عرب ية Number). (Language Line ب رق م ات صل.ب ال مجان ل ك Kreyòl Ayisyen (Haitian Creole) - ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (Language Line Number). Français (French) - ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (Language Line Number). Polski (Polish) - UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (Language Line Number). Português (Portuguese) - ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (Language Line Number). Italiano (Italian) - ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (Language Line Number). Deutsch (German) - ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (Language Line Number). 日本語 (Japanese) - 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (Language Line Number) まで お電話にてご連絡ください This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law ) via grant H89HA The information or content and conclusions are those of Fulton County (Atlanta EMA) Ryan White Part A Program and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. Government. 2 Fulton County Part A Program Manual June 2016

4 Table of Contents GENERAL INFORMATION... 4 Purpose... 4 Legislative and Regulatory Requirements... 4 Fulton County Ryan White Part A Program Overview... 8 Introduction... 8 Service Categories Service Definitions General Program Requirements Funding Exclusions Client Eligibility Confidentiality CAREWare Contractual Requirements Cumulative Contract Expenditure Report Standards of Care Clinical Quality Management Site Visits Vendor Selection/Procurement National HIV/AIDS Strategy Affordable Care Act HIV Care Continuum Implementation Plan Integrated Plan Definitions Fulton County Part A Program Manual June 2016

5 GENERAL INFORMATION Purpose The Fulton County Ryan White Program has developed this manual to further the effective implementation of Ryan White Part A Program grant management and service delivery. The purpose is to standardize processes and to facilitate compliance with legislative and programmatic requirements. Legislative and Regulatory Requirements The Ryan White Part A program is authorized by Part A of Title XXVI of the Public Health Services Act, as amended by the Ryan White Treatment Extension Act of 2009 (hereinafter referred to as the Ryan White HIV/AIDS Program or RWHAP). Part A funds, which include Minority AIDS Initiative (MAI) funds, provide direct financial assistance to Eligible Metropolitan Areas (EMAs) that have been the most severely affected by the HIV epidemic to assist EMAs in developing or enhancing access to a comprehensive continuum of high quality, community-based care for low-income individuals and families with HIV disease. The following statutes, regulations, administrative requirements, OMB Circulars, HHS Grants Policy Directives are applicable to Ryan White HIV/AIDS Program grants: 1. The Ryan White HIV/AID Program under Title XXVI of the Public Health Service (PHS) Act as amended by the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law , October 2009) 2. National Policy Requirements 2 CFR Part 170 Transparency Act Reporting Subaward and Executive Compensation; 2 CFR Part 175 Award term for trafficking in persons; 2 CFR 376 HHS codification of non-procurement debarment and suspension; 2 CFR 382 HHS codification of Drug-Free Workplace Act common rule; 45 CFR 46 Protection of Human Subjects; 45 CFR 80, 81, 84, 85, 86, 90, 91 HHS codification of nondiscrimination statutes; 45 CFR 87 Equal Treatment for Faith-Based Organizations; and, 45 CFR 93 HHS codification of Byrd Anti-Lobbying Amendment common rule. 4 Fulton County Part A Program Manual June 2016

6 3. Program Regulations: Issued by HRSA, these regulations generally have a statutory basis and elaborate on the requirements contained in the authorizing legislation, Public Health Service Act, Sections (42 USC 300ff ff-20), as amended by the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law ), and Program policies and requirements. These are supplemented by Policies and Program letters issued periodically by HAB which are available at: Universal Monitoring Standards Part A Fiscal Monitoring Standards Part A Program Monitoring Standards 4. Administrative Requirements: Provides definitions and requirements for a range of administrative requirements for the agency and recipients. 45 CFR Part 74 Uniform Administrative Requirements for Awards and Sub awards to Institutions of Higher Education, Hospitals, Other Nonprofit Organizations, and Commercial Organizations. [HHS codification of OMB Circular A-110] Applicable to discretionary and mandatory formula grants. 45 CFR Part 92 Uniform Administrative Requirements for Grants and Cooperative Agreements to State, Local, and Tribal Governments. [HHS codification of OMB Circular A-102] Applicable to discretionary and mandatory formula grants. 5. OMB Circulars 2 CFR Part 220 Cost Principles for Educational Institutions (OMB Circular A-21). 2 CFR Part 225 Cost Principles for State, Local, and Indian Tribal Governments (OMB Circular A-87). 2 CFR Part 230 Cost Principles for Non-Profit Organizations (OMB Circular A- 122). 5 Fulton County Part A Program Manual June 2016

7 OMB Circular A-133 Audits of States, Local Governments, and Non-Profit Agencies. 5. HHS Grants Policy Statement, January 1, 2007 The Office of Management and Budget (OMB) has consolidated, in 2 CFR Part 200, the uniform grants administrative requirements, cost principles, and audit requirements for all organization types (state and local governments, non-profit and educational institutions, and hospitals) receiving federal awards. These requirements, known as the Uniform Guidance, are applicable to recipients and subrecipients of federal funds. The OMB Uniform Guidance has been codified by the Department of Health and Human Services (HHS) in 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards. =L&mc=true&r=PART&n=pt RWHAP grant and cooperative agreement recipients and subrecipients should be thoroughly familiar with 45 CFR Part 75. Recipients are required to monitor the activities of the subrecipient to ensure the subaward is used for authorized purposes in compliance with applicable statute, regulations, policies and the terms and conditions of the award (see 45 CFR ). =L&mc=true&r=PART&n=pt #sg _1344_675_1350.sg4 45 CFR Part 75, Subpart E Cost Principles must be used in determining allowable costs that may be charged to a RWHAP award. Costs must be necessary and reasonable to carry out approved project activities, allocable to the funded project, and allowable under the Cost Principles, or otherwise authorized by the RWHAP statute. The treatment of costs must be consistent with recipient or subrecipient policies and procedures that apply uniformly to both federallyfinanced and other non-federally funded activities. =L&mc=true&r=PART&n=pt #sp e 6 Fulton County Part A Program Manual June 2016

8 6. The HHS Grants Policy Statement (GPS) serves as the general terms and conditions of HRSA s discretionary grant and cooperative agreement awards to organizations. Recipients are subject to these general terms and conditions unless there are statutory, regulatory, or award-specific requirements to the contrary (as specified in individual Notices of Award). The GPS can be found at 7. The Code of Federal Regulations, 74 C.F.R (a) and 2 C.F.R (a) state that [r]ecipients are responsible for managing and monitoring each project, program, sub-award, function, or activity supported by the award. Under 2 C.F.R , monitoring generally includes a need for: Performance reports; Comparison of actual accomplishments with goals and objectives; Analysis and explanation of cost overruns; Notification to the Federal awarding agency of developments that have a significant impact on the award supported activities; and, Site visits Monitoring Requirements Federal regulations explicitly state that recipients have a responsibility to monitor their funded providers to ensure they are using their Federal grant program funds in accordance with program requirements. Title 45 CFR 92.40, monitoring and reporting program performance; monitoring by recipients: Recipients are responsible for managing the day-to-day operations of grant and subgrant supported activities. Recipients must monitor grant and subgrant supported activities to assure compliance with applicable Federal requirements and that performance goals are being achieved. Recipient monitoring must cover each program, function, or activity. Title 45 CFR 74.51, monitoring and reporting program performance: Recipients are responsible for managing and monitoring each project, program, subaward, function or activity supported by the award. Recipients shall monitor 7 Fulton County Part A Program Manual June 2016

9 subawards to ensure that subrecipients have met the audit requirements as set forth in The Federal regulations go on to affirm that recipients are required to maintain, as set forth in 45 CFR Sec : (a) system for contract administration to ensure subrecipient conformance with the terms, conditions and specifications of the contract and to ensure adequate and timely follow-up of all purchases [Recipients] shall evaluate subrecipient performance and document, as appropriate, whether subrecipients have met the terms, conditions, and specifications of the contract. Fulton County Ryan White Part A Program Overview 8 Fulton County Part A Program Manual June 2016 Goal: The goal of the Fulton County Ryan White Part A (Part A Program) is to provide for the development, organization, coordination and operation of an effective and cost-efficient system for the delivery of essential services to individuals and families affected by HIV disease in order to improve health outcomes. Introduction Program Organization: POLICIES are the rules or guidelines by which an agency operates. They may be general or specific, but always reflect the philosophy, mission, and goals of the organization. Policies are generally approved by the organization s leadership and implemented by management. They define operations such as staff organization, services, hours, and conditions for business transactions. They might, among many other functions, set the criteria for eligibility for services, establish the agency's commitment to confidentiality in all functions, or processes for contract management or monitoring. PROCEDURES are the methods, the sets of instructions, by which policies are carried out. They give specific steps for accomplishing tasks, handling information, and making service delivery decisions. They may specify, for example, how phones are answered, how appointments are scheduled, who makes record entries, how bills are paid, how grievances are addressed, and what steps are taken in cases of medical emergency or a security threat.

10 Program Manual Components: This Program Manual is comprised of several inter-related and inter-dependent parts: 1. This Document which provides an overview and framework 2. A series of Policy and Procedure Notices (PPNs), incorporated herein by reference 3. An Index of PPNs, incorporated herein by reference 4. The Ryan White Master Contract, incorporated herein by reference 5. Quality Management Plan, incorporated herein by reference 6. Standards and Indicators, incorporated herein by reference 7. Atlanta EMA CAREWare Manual, incorporated herein by reference 8. HRSA/HAB Fiscal Monitoring Standards: 9. HRSA/HAB Program Monitoring Standards: HRSA/HAB Universal Monitoring Standards: HRSA/HAB National Monitoring Standards Frequently Asked Questions: 9 Fulton County Part A Program Manual June 2016 Policy Notices Clusters of business transactions and requirements divide the Policy and Procedure Notices. There are four categories of Policy Notices: 1. Programmatic Policies and Procedures (PPPN) which apply to subrecipients 2. Fiscal Policies and Procedures (FPPN) which apply to subrecipients 3. Recipient Policies and Procedures (RPPN) which apply to subrecipients 4. Policy Clarification Notices (PCN) which relate to an approved PPPN or FPPN and provide additional information related to the referenced policy. Policy and Procedure Notices typically will contain: Summary and Purpose of PPN provides a background, description and intent of the policy. Authority legislation, regulation, or other governing language, or origin of the policy and the entity that provides oversight for implementation of the policy and procedure.

11 Policy and Procedures action items required for the subrecipient to be in compliance with the policy. Verification the process and/or documents which will be used to verify compliance with Policies and Procedures Approval Date the effective date of the policy including any revision dates. Updates The development of Ryan White Part A Program policies and procedures is an iterative process requiring ongoing refinements that could be driven by changes in legislation or County practices, administrative, fiscal, programmatic, or continuous quality improvement. Hence, any updates or revisions to these policies and procedures will be provided by the Ryan White Part A Program Office in the form of a Policy Clarification Notice (PCN) identifying the policy or procedure change, the effective date, and changes in the policy or a new Policy and Procedure Notice (PPN). Any revised policies and procedures are to be inserted in the appropriate section of the manual and shared with appropriate staff responsible for implementation of the policy and procedure. Questions Questions regarding the implementation of the policies and procedures contained herein should be directed to the Ryan White Part A Program Office, typically through the designated Project Officer. Any exemption to these policies and procedures will be approved in writing by an authorized agent of the Ryan White Part A Program. Additional Guidance Ryan White HIV/AIDS Program Part A Manual, US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Revised Additional information for subrecipients may be found at the Fulton County Ryan White Part A website: 10 Fulton County Part A Program Manual June 2016

12 Service Categories In every instance, HAB expects that services supported with RWHAP funds will (1) fall within the legislatively-defined range of services, (2) as appropriate, within Part A, have been identified as a local priority by the HIV Health Services Planning Council 1, and (3) meet documented needs and contribute to the establishment of a continuum of care. RWHAP funds are intended to support only the HIV-related needs of eligible individuals. Recipients and subrecipients must be able to make an explicit connection between any service supported with RWHAP funds and the intended client s HIV status, or care-giving relationship to a person with HIV. Below is the list of HRSA approved service categories. AIDS Drug Assistance Program Treatments AIDS Pharmaceutical Assistance Child Care Services Early Intervention Services (EIS) Emergency Financial Assistance Food Bank/Home Delivered Meals Health Education/Risk Reduction Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals Home and Community-Based Health Services Home Health Care Hospice Services Housing Legal Services Linguistic Services Medical Case Management, including Treatment Adherence Services Medical Nutrition Therapy Medical Transportation Mental Health Services Non-medical Case Management Services Oral Health Care Other Professional Services Outpatient/Ambulatory Health Services Outreach Services Permanency Planning 1 The HIV Health Services Planning Council for the Atlanta EMA is the Metropolitan Atlanta HIV Health Services Planning Council. 11 Fulton County Part A Program Manual June 2016

13 Psychosocial Support Services Referral for Health Care and Support Services Rehabilitation Services Respite Care Substance Abuse Outpatient Care Substance Abuse Services (Residential) Not all services may have been prioritized or may have funds allocated by the Metropolitan Atlanta HIV Health Services Planning Council. For the most current list of service categories prioritized by the Planning Council please see the Ryan White website: Please also see PPPN-005 Local Policies Affecting Funding. Service Definitions RWHAP funds are intended to support only the HIV-related needs of clients. All services provided to HIV-positive, HIV-indeterminate (infants <2 years only), and HIV-affected clients must always promote the medical outcomes of the infected client. Services are divided into three groups: Administrative and technical services Core medical services Support services Administrative and Technical Services Planning or evaluation services are the systematic (orderly) collection of information about the characteristics, activities, and outcomes of services or programs to assess the extent to which objectives have been achieved, to identify needed improvements, and/or to make decisions about future programming. Administrative or technical support services are the provision of quality and responsive support services to an organization. These may include human resources, financial management, and administrative services (e.g., property management, warehousing, printing/publications, libraries, claims, medical supplies, and conference/training facilities). Fiscal intermediary services are the provision of administrative services to the recipient of record by a pass-through organization. The responsibilities of these organizations 12 Fulton County Part A Program Manual June 2016

14 may include determining the eligibility of RWHAP recipients, deciding how funds are allocated to recipients, awarding RWHAP funds to recipients, monitoring recipients for compliance with RWHAP-specific requirements, and completing required reports. Other fiscal services are the receipt or collection of reimbursements on behalf of health care professionals for services rendered or other related fiduciary services pursuant to health care professional contracts. Technical assistance services identify the need for and the delivery of practical program and technical support to the RWHAP community. These services should help recipients, planning bodies, and communities affected by HIV and AIDS to design, implement, and evaluate RWHAP-supported planning and primary care service-delivery systems. Capacity development services are services to develop a set of core competencies that in turn help organizations foster effective HIV health care services, including the quality, quantity, and cost-effectiveness of such services. These competencies also sustain the infrastructure and resource base necessary to develop and support these services. Core competencies include management of program finances; effective HIV service delivery, including quality assurance, personnel management, and board development; resource development, including preparation of grant applications to obtain resources and purchase supplies/equipment; service evaluation; and development of cultural competency. Quality management services comprise systematic processes with identified leadership, accountability, and dedicated resources using data and measurable outcomes to determine progress toward relevant, evidence-based benchmarks. Quality management programs should focus on linkages, efficiencies, and provider and client expectations in addressing outcome improvement, and they need to adapt to change. The process is continuous and should fit in the framework of other program quality assurance and quality improvement activities, such as the Institute for Healthcare Improvement, the Joint Commission on the Accreditation of Healthcare Organizations, and Medicaid. Data collected as part of this process should be fed back into the quality management process to assure that goals are accomplished and outcomes improved. Quality management is a continuous process to improve how a health or social service meets or exceeds established professional standards and user expectations. The purpose of a quality management program is to ensure that (1) services adhere to PHS guidelines and established clinical practice; (2) program improvements include supportive services; (3) supportive services are linked to access and adherence to medical care; and (4) demographic, clinical, and utilization data are used to evaluate and 13 Fulton County Part A Program Manual June 2016

15 address characteristics of the local epidemic. For further information on quality management, please refer to the resources available at: The following core medical and support service categories are important to assist in the diagnosis of HIV infection, linkage to care for seropositive individuals, retention in care, and the provision of HIV treatment. To be an allowable cost under the RWHAP, all services must relate to HIV diagnosis, care and support and must adhere to established HIV clinical practice standards consistent with HHS treatment guidelines. In addition, all providers must be appropriately licensed and in compliance with state and local regulations. Recipients are required to work toward the development and adoption of service standards for all RWHAP-funded services. Core Medical Services Core medical services are specified in the Ryan White HIV/AIDS Treatment Extension Act of They are a set of essential, direct health care services provided to RWHAP clients who are HIV positive or HIV indeterminate (infants <2 years only), with one exception. HIV-negative clients may receive HIV counseling and testing (HC&T) services under Early Intervention Services for Part A; HC&T data are reported in the Provider Report. HRSA requires that Ryan White recipients assure that not less than 75% of its funding is used to provide the core medical services that are needed in the EMA for individuals who are identified and eligible under the Ryan White HIV/AIDS Program before spending any resources on support services. See: RPPN-004 Core Medical Services Spending RPPN-005 Support Services Spending Reference: Ryan White HIV/AIDS Program Services: Eligible Individuals & Allowable Uses of Funds, HAB Policy Clarification Notice (PCN) #16-02 which replaces # Fulton County Part A Program Manual June 2016

16 HIV/AIDS Bureau (HAB) Ryan White HIV/AIDS Program (RWHAP) Policy Clarification Notice 16-02: Eligible Individuals and Allowable Uses of Funds Frequently Asked Questions Outpatient/Ambulatory Health Services (OAHS) are diagnostic and therapeutic services provided directly to a client by a licensed healthcare provider in an outpatient medical setting. Outpatient medical settings include clinics, medical offices, and mobile vans where clients do not stay overnight. Emergency room or urgent care services are not considered outpatient settings. Allowable activities include: Medical history taking Physical examination Diagnostic testing, including laboratory testing Treatment and management of physical and behavioral health conditions Behavioral risk assessment, subsequent counseling, and referral Preventive care and screening Pediatric developmental assessment Prescription, and management of medication therapy Treatment adherence Education and counseling on health and prevention issues Referral to and provision of specialty care related to HIV diagnosis Program Guidance: Treatment Adherence services provided during an Outpatient/ Ambulatory Health Service visit should be reported under the OAHS category whereas Treatment Adherence services provided during a Medical Case Management visit should be reported in the Medical Case Management service category. See Policy Notice 13-04: Clarifications Regarding Clients Eligibility for Private Health Insurance and Coverage of Services by Ryan White HIV/AIDS Program See Early Intervention Services Priority Service Category. AIDS Drug Assistance Program Treatments: The AIDS Drug Assistance Program (ADAP) is a state-administered program authorized under Part B of the RWHAP to provide FDAapproved medications to low-income clients with HIV disease who have no coverage or limited health care coverage. ADAPs may also use program funds to purchase health insurance for eligible clients and for services that enhance access to, adherence to, and monitoring of antiretroviral therapy. RWHAP ADAP recipients must conduct a cost 15 Fulton County Part A Program Manual June 2016

17 effectiveness analysis to ensure that purchasing health insurance is cost effective compared to the cost of medications in the aggregate. Eligible ADAP clients must be living with HIV and meet income and other eligibility criteria as established by the state. Program Guidance: See HAB PCN 07-03: The Use of Ryan White HIV/AIDS Program, Part B (formerly Title II), AIDS Drug Assistance Program (ADAP) Funds for Access, Adherence, and Monitoring Services; HAB PCN 13-05: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Private Health Insurance; and, HAB PCN 13-06: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Medicaid See also AIDS Pharmaceutical Assistance and Emergency Financial Assistance pdf AIDS Pharmaceutical Assistance services fall into two categories, based on RWHAP Part funding. 1. Local Pharmaceutical Assistance Program (LPAP) is operated by a RWHAP Part A or B recipient or subrecipient as a supplemental means of providing medication assistance when an ADAP has a restricted formulary, waiting list and/or restricted financial eligibility criteria. RWHAP Part A or B recipients using the LPAP service category must establish the following: Uniform benefits for all enrolled clients throughout the service area A recordkeeping system for distributed medications An LPAP advisory board A drug formulary approved by the local advisory committee/board A drug distribution system A client enrollment and eligibility determination process that includes screening for ADAP and LPAP eligibility with rescreening at minimum of every six months Coordination with the state s RWHAP Part B ADAP A statement of need should specify restrictions of the state ADAP and the need for the LPAP 16 Fulton County Part A Program Manual June 2016

18 Implementation in accordance with requirements of the 340B Drug Pricing Program and the Prime Vendor Program 2. Community Pharmaceutical Assistance Program is provided by a RWHAP Part C or D recipient for the provision of long-term medication assistance to eligible clients in the absence of any other resources. The medication assistance must be greater than 90 days. Program Guidance: For LPAPs: Only RWHAP Part A grant award funds or Part B Base award funds may be used to support an LPAP. ADAP funds may not be used for LPAP support. LPAP funds are not to be used for Emergency Financial Assistance. Emergency Financial Assistance may assist with medications not covered by the LPAP. For Community Pharmaceutical Assistance: This service category should be used when RWHAP Part C or D funding is expended to routinely refill medications. RWHAP Part C or D recipients should use the Outpatient Ambulatory Health Services or Emergency Financial Assistance service for non-routine, short-term medication assistance. See Ryan White HIV/AIDS Program Part A and B National Monitoring Standards See also LPAP Policy Clarification Memo See also AIDS Drug Assistance Program Treatments and Emergency Financial Assistance Priority Service Categories. Oral Health Care includes diagnostic, preventive, and therapeutic services provided by a dental health care professional licensed to provide health care in the State or jurisdiction, including general dental practitioners, dental specialists, and dental hygienists, as well as licensed and trained dental assistants. Early Intervention Services (EIS) is defined by RWHAP legislation see 2651(e) of the Public Health Service Act. Program Guidance: The elements of EIS often overlap with other service category descriptions; however, EIS is the combination of such services rather than a stand-alone service. RWHAP Part A recipients and subrecipients should be aware of programmatic expectations that stipulate the allocation of funds into specific service categories. 17 Fulton County Part A Program Manual June 2016

19 RWHAP Parts A EIS services must include the following four components: 1. Targeted HIV testing to help the unaware learn of their HIV status and receive referral to HIV care and treatment services if found to be HIV-infected Recipients must coordinate these testing services with other HIV prevention and testing programs to avoid duplication of efforts HIV testing paid for by EIS cannot supplant testing efforts paid for by other sources 2. Referral services to improve HIV care and treatment services at key points of entry 3. Access and linkage to HIV care and treatment services such as HIV Outpatient/Ambulatory Health Services, Medical Case Management, and Substance Abuse Care 4. Outreach Services and Health Education/Risk Reduction related to HIV diagnosis Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals (HIP), provides financial assistance for eligible clients living with HIV to maintain continuity of health insurance or to receive medical and pharmacy benefits under a health care coverage program. To use RWHAP funds for health insurance premium and cost-sharing assistance, a RWHAP Part recipient must implement a methodology that incorporates the following requirements: RWHAP Part recipients must ensure that clients are buying health coverage that, at a minimum, includes at least one drug in each class of core antiretroviral therapeutics from the Department of Health and Human Services (HHS) treatment guidelines along with appropriate HIV outpatient/ambulatory health services RWHAP Part recipients must assess and compare the aggregate cost of paying for the health coverage option versus paying for the aggregate full cost for medications and other appropriate HIV outpatient/ambulatory health services, and allocate funding to Health Insurance Premium and Cost Sharing Assistance only when determined to be cost effective The service provision consists of either or both of the following: Paying health insurance premiums to provide comprehensive HIV Outpatient/Ambulatory Health Services and pharmacy benefits that provide a full range of HIV medications for eligible clients Paying cost-sharing on behalf of the client Program Guidance: Traditionally, RWHAP Parts A and B funding support health insurance premiums and cost-sharing assistance. If a RWHAP Part C or D recipient has 18 Fulton County Part A Program Manual June 2016

20 the resources to provide this service, an equitable enrollment policy must be in place and it must be cost-effective and sustainable. See HAB PCN 07-05: Program Part B ADAP Funds to Purchase Health Insurance; HAB PCN 13-05: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Private Health Insurance; HAB PCN 13-06: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Medicaid; and, pdf HAB PCN 14-01: Revised 4/3/2015: Clarifications Regarding the Ryan White HIV/AIDS Program and Reconciliation of Premium Tax Credits under the Affordable Care Act Home Health Care is the provision of services in the home that are appropriate to a client s needs and are performed by licensed professionals. Services must relate to the client s HIV disease and may include: Administration of prescribed therapeutics (e.g. intravenous and aerosolized treatment, and parenteral feeding) Preventive and specialty care Wound care Routine diagnostics testing administered in the home Other medical therapies Program Guidance: The provision of Home Health Care is limited to clients that are homebound. Home settings do not include nursing facilities or inpatient mental health/substance abuse treatment facilities. Medical Nutrition Therapy includes: Nutrition assessment and screening Dietary/nutritional evaluation Food and/or nutritional supplements per medical provider s recommendation Nutrition education and/or counseling 19 Fulton County Part A Program Manual June 2016

21 These services can be provided in individual and/or group settings and outside of HIV Outpatient/Ambulatory Health Services. Program Guidance: All services performed under this service category must be pursuant to a medical provider s referral and based on a nutritional plan developed by the registered dietitian or other licensed nutrition professional. Services not provided by a registered/licensed dietician should be considered Psychosocial Support Services under the RWHAP. See Food-Bank/Home Delivered Meals Hospice Services are end-of-life care services provided to clients in the terminal stage of an HIV-related illness. Allowable services are: Mental health counseling Nursing care Palliative therapeutics Physician services Room and board Program Guidance: Services may be provided in a home or other residential setting, including a non-acute care section of a hospital that has been designated and staffed to provide hospice services. This service category does not extend to skilled nursing facilities or nursing homes. To meet the need for hospice services, a physician must certify that a patient is terminally ill and has a defined life expectancy as established by the recipient. Counseling services provided in the context of hospice care must be consistent with the definition of mental health counseling. Palliative therapies must be consistent with those covered under respective state Medicaid programs. Home and Community-Based Health Services are provided to a client living with HIV in an integrated setting appropriate to a client s needs, based on a written plan of care established by a medical care team under the direction of a licensed clinical provider. Services include: Appropriate mental health, developmental, and rehabilitation services Day treatment or other partial hospitalization services Durable medical equipment Home health aide services and personal care services in the home Program Guidance: Inpatient hospitals, nursing homes, and other long-term care facilities are not considered an integrated setting for the purposes of providing home and community-based health services. 20 Fulton County Part A Program Manual June 2016

22 Mental Health Services are the provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment, and counseling services offered to clients living with HIV. Services are based on a treatment plan, conducted in an outpatient group or individual session, and provided by a mental health professional licensed or authorized within the state to render such services. Such professionals typically include psychiatrists, psychologists, and licensed clinical social workers. Program Guidance: Mental Health Services are allowable only for HIV-infected clients. See Psychosocial Support Services Substance Abuse Outpatient Care is the provision of outpatient services for the treatment of drug or alcohol use disorders. Services include: Screening Assessment Diagnosis, and/or Treatment of substance use disorder, including: Pretreatment/recovery readiness programs Harm reduction o Behavioral health counseling associated with substance use disorder Outpatient drug-free treatment and counseling Medication assisted therapy Neuro-psychiatric pharmaceutical Relapse prevention Program Guidance: Acupuncture therapy may be allowable under this service category only when, as part of a substance use disorder treatment program funded under the RWHAP, it is included in a documented plan. Syringe access services are allowable, to the extent that they comport with current appropriations law and applicable HHS guidance, including HRSA- or HAB-specific guidance and approval. See Substance Abuse Services (residential) Medical Case Management, including Treatment Adherence Services is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. Medical Case Management includes all types of 21 Fulton County Part A Program Manual June 2016

23 case management encounters (e.g., face-to-face, phone contact, and any other forms of communication). Key activities include: Initial assessment of service needs Development of a comprehensive, individualized care plan Timely and coordinated access to medically appropriate levels of health and support services and continuity of care Continuous client monitoring to assess the efficacy of the care plan Re-evaluation of the care plan at least every 6 months with adaptations as necessary Ongoing assessment of the client s and other key family members needs and personal support systems Treatment adherence counseling to ensure readiness for and adherence to complex HIV treatments Client-specific advocacy and/or review of utilization of services In addition to providing the medically oriented services above, Medical Case Management may also provide benefits counseling by assisting eligible clients in obtaining access to other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer s Patient Assistance Programs, other state or local health care and supportive services, and insurance plans through the health insurance Marketplaces/Exchanges). Program Guidance: Medical Case Management services have as their objective improving health care outcomes whereas Non-Medical Case Management Services have as their objective providing guidance and assistance in improving access to needed services. Visits to ensure readiness for, and adherence to, complex HIV treatments shall be considered Medical Case Management or Outpatient/Ambulatory Health Services. Treatment Adherence Services provided during a Medical Case Management visit should be reported in the Medical Case Management service category whereas Treatment Adherence services provided during an Outpatient/Ambulatory Health Service visit should be reported under the Outpatient/Ambulatory Health Services category. Support Services Support services are a set of services needed to achieve medical outcomes that affect the HIV-related clinical status of a person living with HIV/AIDS. Support services may be provided to HIV-positive and HIV-indeterminate clients (infant <2 years only) as needed. 22 Fulton County Part A Program Manual June 2016

24 Support services may also be provided to HIV-affected clients. However, the services provided to HIV-affected clients must always support a medical outcome for the HIVpositive client or HIV indeterminate client (infant <2 years only). Non-Medical Case Management Services (NMCM) provide guidance and assistance in accessing medical, social, community, legal, financial, and other needed services. Non- Medical Case management services may also include assisting eligible clients to obtain access to other public and private programs for which they may be eligible, such as Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer s Patient Assistance Programs, other state or local health care and supportive services, or health insurance Marketplace plans. This service category includes several methods of communication including face-to-face, phone contact, and any other forms of communication deemed appropriate by the RWHAP Part recipient. Key activities include: Initial assessment of service needs Development of a comprehensive, individualized care plan Continuous client monitoring to assess the efficacy of the care plan Re-evaluation of the care plan at least every 6 months with adaptations as necessary Ongoing assessment of the client s and other key family members needs and personal support systems Program Guidance: Non-Medical Case Management Services have as their objective providing guidance and assistance in improving access to needed services whereas Medical Case Management services have as their objective improving health care outcomes. Child Care Services supports intermittent child care services for the children living in the household of HIV-infected clients for the purpose of enabling clients to attend medical visits, related appointments, and/or RWHAP-related meetings, groups, or training sessions. Allowable use of funds includes: A licensed or registered child care provider to deliver intermittent care Informal child care provided by a neighbor, family member, or other person (with the understanding that existing federal restrictions prohibit giving cash to clients or primary caregivers to pay for these services) Program Guidance: The use of funds under this service category should be limited and carefully monitored. Direct cash payments to clients are not permitted. 23 Fulton County Part A Program Manual June 2016

25 Such arrangements may also raise liability issues for the funding source which should be carefully weighed in the decision process. Emergency Financial Assistance provides limited one-time or short-term payments to assist the RWHAP client with an emergent need for paying for essential utilities, housing, food (including groceries, and food vouchers), transportation, and medication. Emergency financial assistance can occur as a direct payment to an agency or through a voucher program. Program Guidance: Direct cash payments to clients are not permitted. It is expected that all other sources of funding in the community for emergency financial assistance will be effectively used and that any allocation of RWHAP funds for these purposes will be as the payer of last resort, and for limited amounts, uses, and periods of time. Continuous provision of an allowable service to a client should not be funded through emergency financial assistance. See AIDS Drug Assistance Program Treatments, AIDS Pharmaceutical Assistance, and other corresponding categories Food Bank/Home Delivered Meals refers to the provision of actual food items, hot meals, or a voucher program to purchase food. This also includes the provision of essential non-food items that are limited to the following: Personal hygiene products Household cleaning supplies Water filtration/purification systems in communities where issues of water safety exist. Program Guidance: Unallowable costs include household appliances, pet foods, and other non-essential products. See Medical Nutrition Therapy. Nutritional services and nutritional supplements provided by a registered dietitian are considered a core medical service under the RWHAP. Health Education/Risk Reduction is the provision of education to clients living with HIV about HIV transmission and how to reduce the risk of HIV transmission. It includes sharing information about medical and psychosocial support services and counseling with clients to improve their health status. Topics covered may include: Education on risk reduction strategies to reduce transmission such as preexposure prophylaxis (PrEP) for clients partners and treatment as prevention 24 Fulton County Part A Program Manual June 2016

26 Education on health care coverage options (e.g., qualified health plans through the Marketplace, Medicaid coverage, Medicare coverage) Health literacy Treatment adherence education Program Guidance: Health Education/Risk Reduction services cannot be delivered anonymously. See Early Intervention Services Housing Services provide limited short-term assistance to support emergency, temporary, or transitional housing to enable a client or family to gain or maintain outpatient/ambulatory health services. Housing-related referral services include assessment, search, placement, advocacy, and the fees associated with these services. Housing services are transitional in nature and for the purposes of moving or maintaining a client or family in a long-term, stable living situation. Therefore, such assistance cannot be provided on a permanent basis and must be accompanied by a strategy to identify, relocate, and/or ensure the client or family is moved to, or capable of maintaining, a long-term, stable living situation. Eligible housing can include housing that provides some type of medical or supportive services (such as residential substance use disorder services or mental health services, residential foster care, or assisted living residential services) and housing that does not provide direct medical or supportive services, but is essential for a client or family to gain or maintain access to and compliance with HIV-related outpatient/ambulatory health services and treatment. Program Guidance: RWHAP Part recipients must have mechanisms in place to allow newly identified clients access to housing services. Upon request, RWHAP recipients must provide HAB with an individualized written housing plan, consistent with RWHAP Housing Policy 11-01, covering each client receiving short term, transitional and emergency housing services. RWHAP recipients and local decision making planning bodies, (i.e., Part A and Part B) are strongly encouraged to institute duration limits to provide transitional and emergency housing services. The US Department of Housing and Urban Development (HUD) defines transitional housing as up to 24 months and HRSA/HAB recommends that recipients consider using HUD s definition as their standard. Housing services funds cannot be in the form of direct cash payments to clients and cannot be used for mortgage payments. 25 Fulton County Part A Program Manual June 2016